Reaching sources without a subscription
No writer holds a subscription to every journal, database and book, so much of what a document needs sits behind a pay wall. Without a subscription it is reached by other routes: free full text and open-access copies, libraries that admit the public or sell memberships, the authors themselves, article purchase, rental and document delivery, the access that comes with a membership or an entitlement, and a librarian who knows where the material is held.
The pay wall and its price
No one has subscriptions to every article or resource. When the article or database a writer wants is not available free online, a click on "access full text" brings up the pay wall, the web page that asks for a credit card number or PayPal account information.
In 2013 article charges of $20 or $30 were not uncommon, and they could add up to substantial sums when a project needed many papers. In 2012, 24 hours of access to one article in the Journal of Visual Communication in Medicine cost US$86.00, the highest such fee one writer had come across, while an annual individual subscription to EMWA's journal Medical Writing cost US$85.00 and its individual articles cost US$48.00 plus tax. Excellent resources on the ethical aspects of writing, however, were available free of charge.
There are several ways of trying to get around the pay wall. In one journal editor's view, the best answer, though only a partial one, is to become as savvy as possible about finding information that is free to everyone or may potentially be free to the writer. When a member of a medical writers' association asked in 2011 how to reach journals online without paying for several subscriptions, other members suggested free articles from libraries, databases, websites and document delivery services, as well as some paid but cost-effective journals.
Knowing what is needed
A search starts from knowing what is sought: a journal article, a report, database information, a book or a chapter. In one medical librarian's experience, many doctors who thought they were looking for a journal article were in fact looking for a paper presented at a conference or something completely different. Once the item is known, a strategy for getting it becomes a little easier to form.
Free full text and open access
For a freelancer whose client does not provide all the reference sources needed, the internet offers a wealth of robust information free of charge.
PubMed, the National Library of Medicine's database of indexed citations and abstracts, is free, and many of the articles it lists are free as well. The easiest way to retrieve only free articles is to limit the search to articles with free full text available, either with the filter on the left side of the results page or by adding free full text[sb] to the search string, as in publishing AND free full text[sb]. PubMed Central is one of the larger repositories of open-access journals, and its published list of participating journals gives holdings dates, when current articles will become freely available, and whether a journal deposits all or only selected articles from each issue. PubMed Central also holds manuscripts supported by National Institutes of Health funding, which may differ in minor ways from the final version the journal published.
Repositories where authors and institutions self-archive a version of their articles can be found through two directories, OpenDOAR, the Directory of Open Access Repositories, and ROAR, the Registry of Open Access Repositories. The Directory of Open Access Journals lists thousands of open-access journals, such as those published by BioMed Central and the Public Library of Science. Sources of free, open-access articles include the Directory of Open Access Journals, HighWire's list of free articles, the Public Library of Science and Free Medical Journals. In 2012 one medical writer judged open-access sources to be pretty good, and every once in a while she paid at the last minute for a $30 reference for a big project.
For researching health trends, one medical writer found a global health statistics site very useful: to build scene-setting slides on disease prevalence rates, a writer could download the data for each country as a CSV file and make graphs from it. Other free sources are BioMed Central and PubMed.
For academic references, Google Scholar is one of the best ways to search through journal articles, although not everything it finds is free to download. In 2015 a free JSTOR account gave access to up to three articles every two weeks across a huge range of journals, primary sources and books, with a paid service for more. Websites for searching for cited literature include Google Scholar, Pubget, SUMSearch, Scirus, the TRIP Database, Merck Medicus, BioMed Central and PubMed Central. Entering an article title into an online search engine sometimes brings up a PDF.
For books, some of the bigger texts are in ClinicalKey; the PubMed bookshelf or Google Books may show whether a full-text version is freely available; and WorldCat shows whether a library nearby has a copy.
Not all free articles are quality articles or are published in peer-reviewed publications. It is worth checking whether the journal, book or resource is found in a reputable database such as PubMed or is aligned with a reputable repository or publisher. Finding good free medical articles is a bit of an art form, and a writer who searches often enough finds their own technique.
Public, college and medical school libraries
Public libraries and many public college libraries allow members of the public to use their materials and online resources within the library, and some private college libraries do too, though it is best to check with them first. A writer should note every public library, college and medical school they are willing to drive to. Once a writer is in the library, much of what they need will be available on the computer. College and medical school libraries have more medical articles, databases and books, but a public library can have a surprising amount as well.
Some public and private colleges and medical schools offer memberships to the public for a yearly fee, and some colleges provide access to alumni, so a writer can email or telephone a library to ask about a membership. Alumni organisations sometimes offer limited journal access. Membership privileges may include access to some resources from home, borrowing and document delivery, and although a library will not have every resource a writer needs, it can borrow copies of articles or books from other libraries within their borrowing group.
Authors' own copies
Authors are likely to hold official copies of their own journal articles, although publishers may limit the number they receive and distribute. Contacting the author may still be a good option when other efforts have failed. For conference proceedings, various types of report and other grey literature, it may be the only way to obtain them. Getting in touch with the author of a journal article can be surprisingly easy, because the corresponding author's contact information is usually published on a publicly accessible page of the article.
Article purchase, rental and document delivery
Literature searches often retrieve publications for which only a title and perhaps an abstract are freely available. Articles can often be bought, or rented for a limited period of viewing, from the journal's website or through PubMed's Loansome Doc service.
In 2016 DeepDyve, a database of more than 12 million publication records that offers article rentals, gave unlimited online reading for $40 a month, with downloads of articles costing extra. A free account gave registered users 5-minute previews of articles, which may be enough to judge whether an article is truly needed or to look up or verify a quick fact. Its library is not specific to biomedical subjects, so its number of records may not seem impressive beside the 20 million to 30 million in PubMed and Embase, but it may contain records they do not. In 2012 DeepDyve rented full-text articles for small amounts of money, although they could not be printed or saved to a computer.
For medical writers who perform numerous literature searches, the cost of DeepDyve or Loansome Doc may be a small price to pay for increased article access. Many older publications are not available free but can provide essential background information and historical perspective.
Websites for tracking down cited literature include document delivery services and the National Library of Medicine's Loansome Doc, and in 2015 one document supplier, GK Documents, offered reduced article rates to AMWA members. Until its owner died in 2008, Citation Retrieval Services in Los Angeles obtained references for medical writers on days, nights and weekends, and in one writer's account it came to the rescue during rush projects and provided excellent service at a reasonable price.
Access through a membership or an entitlement
People with immediate family members serving on active duty in the US military may be eligible, with sponsorship, to reach resources such as Army Knowledge Online, whose library, in the view of a former director of library services, has a good selection of databases with access to some free full text.
In 2015 the Association of Health Care Journalists gave freelance medical journalists free access to journals and databases, including Elsevier's ClinicalKey and ScienceDirect, UpToDate, the Cochrane Library, Health Affairs, the American Journal of Public Health and the Journal of the American Medical Association, and one writer judged its yearly membership fee of $60 a bargain for those who met its membership requirements.
AMWA membership once included free access to the MD Consult database through the association's website. By 2015 MD Consult had been replaced by ClinicalKey, to which some institutions subscribed while others could not afford the price increase that came with it. AMWA members did not get free access to ClinicalKey but could get a 20% discount on personal subscriptions. For many individuals that price may be too high, and for those who live close to a university with a subscription, it may be worth finding out whether visitor access is available.
Medical librarians
Medical librarians connect people to medical information and resources, because not everything is available online, and the resources that are online often are not free or are not connected in a way that makes them easy to find. A writer should try to find a library or a librarian to work with.
There are several kinds of medical librarian. A solo hospital librarian is a jack of all trades providing resources and services to an entire hospital or even several. An academic medical librarian at a university or medical school is part of a large staff with focused job specialties. An embedded medical librarian is often employed by a large institution and may not be based in the library at all: in hospitals, clinical embedded librarians go on rounds with patient care teams, and the most successful are often embedded within research departments or clinical care groups and work as part of that team.
Some medical libraries have seen fewer people come into the physical library because library resources are easily reached online, and many librarians consider the library web page to be the library too. Counting the people who use its resources online, one large academic medical library serves far more people than it did before the internet age. Because a hospital has no closed times, that library is open almost 12 hours each weekday and 8 hours on Saturday, and electronic resources keep the collection open when the doors are shut and the staff have gone home.
The questions that library receives are now generally more complicated and require more in-depth research and creative digging than in the pre-digital era. Many of the people who now seek its services have already tried to find the information on their own and found that they need help. Each database is unique, and a librarian's job, as one of its librarians describes it, is to know the most effective methods for searching databases and to use that knowledge to retrieve relevant information. Each of its librarians has a job that makes information retrieval easier. A cataloguing librarian adds books, multimedia, journals and other items to the online catalogue so people know what the library holds. User-education librarians create and teach classes on using databases and reference management software, evidence-based medicine and other topics. A systems librarian and a senior librarian make the databases easy to find on the library's website and connect them to the journal subscriptions so that users can retrieve full-text articles, and the senior librarian also works on access from tablets and smartphones to e-books, e-journals, databases and the website. Even librarians who are not embedded in research or clinical teams are often involved in providing patient education literature and serving on hospital committees, task forces and institutional review boards, and a librarian is more likely to be seen carrying a tablet on rounds or troubleshooting a database or full-text journal problem than shelving books.